Believe Yoga
Disclaimer and health screening form
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency contact
-
Area Code
Phone Number
Medical History
Have you ever had any of the following health conditions
Asthma or Breathing problems
Low Blood Pressure
High Blood Pressure
Diabetes
Dizziness/ fainting or vertigo
Circulatory problems
Epilepsy/seizures
Heart problems
Are the health conditions past or active medical history
How would you rate your current health status?
Do you have any current injuries?
Yes
No
If Yes please specify
Have you ever suffered from any of the following injuries?
Neck or spinal injury
Lower back injury
Joint injury (hip, ankle, knee, shoulder, elbow)
Muscular injury
Please detail your injury below ...
Please be aware if practicing yoga with any injury that you stop if you are in any pain. Yoga should not be painful or cause strain or stress to the body.
Yoga for you
Do you practice yoga for any of the following reasons
Stress reduction
Mental clarity
Mindfulness (being in the here and now)
Spiritual reasons / connection / enlightenment
Overall well-being
Confidence
Self-control
Weight management
Flexibility and strength
Managing a particular condition (please specify below)
Specify...
Are you pregnant?
Yes
No
Are you active on a daily basis?
Yes
No
Do you engage in any of the following exercise?
Running
Walking
Cycling
Swimming
Weight Lifting
High intensity interval training/ boot camp
Pilates
Disclaimer: If at any time during the practice you experience discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga that you listen to your body and respect its limites on any given day. Please read the statement below and sign if you are happy to continue I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. I should consult a GP prior to begining in any activity or yoga programme.I recognise that it is my responsibility to notify my teacher of any serious illness or injury before the yoga class. I will not perform any postures to the extent of strain or pain. I will practice at my own ability at all times. I understand that as with any physcial activity there is a risk to physical injury. I acknowlege I have been asked to consult with my GP before beginning yoga and therefore accept full responsibility to any possibility of injury from the class. I accept that neither the instructor, nor the hosting facility is liable for any injury or damages to person or property resulting from taking the class. Signature (for the disclaimer)
Clear
Name
First Name
Last Name
Submit
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